Report on Medicare Compliance

  1. DOJ Intervenes in FCA Suit Filed by ‘Data Whistleblower,’ Adding Insider Allegations

    Report on Medicare Compliance Volume 30, Number 23. June 21, 2021  | Author: Nina Youngstrom  | June 21, 2021 

    For the first time, the Department of Justice (DOJ) has intervened in a novel whistleblower lawsuit against a health care organization that alleged the submission of false claims based on a statistical analysis of Medicare data. DOJ took the ball and ran with it, adding firsthand knowledge of the alleged fraud from insiders to the data from the outsider whistleblower...

  2. HHS Staggers PRF Spending, Reporting Deadlines; Expect Payback Method

    Report on Medicare Compliance Volume 30, Number 23. June 21, 2021  | Author: Nina Youngstrom  | June 21, 2021 

    In guidance on the Provider Relief Fund (PRF) updated June 11, HHS gave hospitals and other providers more bread crumbs to follow in reporting their use of COVID-19 relief money and additional time to get it done...

  3. Summary of New HHS Deadlines for Spending, Reporting Provider Relief Funds

    Report on Medicare Compliance Volume 30, Number 23. June 21, 2021  | Author: Nina Youngstrom  | June 21, 2021 

    The box below, which appeared in HHS’s June 11 updated Provider Relief Fund (PRF) reporting requirements, updates the deadlines for providers to use their PRF money and the reporting time periods.[1]...

  4. In Less Flashy Stark Changes, CMS Hit Period of Disallowance, AKS

    Report on Medicare Compliance Volume 30, Number 23. June 21, 2021  | Author: Nina Youngstrom  | June 21, 2021 

    CMS has made the period of disallowance more flexible under the revised Stark Law regulation,[1] which took effect Jan. 19. It’s one of several changes that was overshadowed by more momentous provisions, including new exceptions for value-based care and revised definitions of fair market value and commercially reasonable, but it’s notable just the same, an attorney said...

  5. With SMRC Therapy Reviews, Consider ADR Requests With Wary Eye

    Report on Medicare Compliance Volume 30, Number 23. June 21, 2021  | Author: Nina Youngstrom  | June 21, 2021 

    It was only a matter of time before postpayment audits would arrive in connection with the permanent end to the hard cap on outpatient physical, occupational and speech therapy that was included in the 2018 Bipartisan Budget Act.[1] The audits are here, courtesy of CMS’ supplemental medical review contractor (SMRC), Noridian Healthcare Solutions LLC...

  6. CMS Transmittals, June 11-17, 2021

    Report on Medicare Compliance Volume 30, Number 23. June 21, 2021  | June 21, 2021 

  7. News Briefs: June 21, 2021

    Report on Medicare Compliance Volume 30, Number 23. June 21, 2021  | Author: Nina Youngstrom  | June 21, 2021 

    ◆ Quest Diagnostics Incorporated, a clinical lab company, agreed to pay $50,000 in a civil monetary penalty settlement with the HHS Office of Inspector General (OIG). According to the settlement, which was obtained through the Freedom of Information Act, the OIG alleged that between Dec. 14 and Dec. 20, 2018, Quest paid remuneration to two medical practices “in the form of nonmonetary compensation when it paid for expenses related to their holiday parties.” The settlement stemmed from Quest’s self-disclosure to the OIG. Quest didn’t admit liability in the settlement, and its attorney declined to comment...

  8. In Rebooting Compliance Program, CO and PO Write Interactive Code, Build Partnerships

    Report on Medicare Compliance Volume 30, Number 22. June 14, 2021  | Author: Nina Youngstrom  | June 14, 2021 

    When the compliance program began 20 years ago at MultiCare, a health system in Washington state, Samantha Karpenko, who worked in revenue cycle there at the time, said it was perceived as “red tape.” There was that sense of compliance as “intimidating,” with more of a police aura...

  9. Radiation Therapy Provider Pays $3.6M in CMP Settlement; OIG: 25 CPT Codes ‘Involved’

    Report on Medicare Compliance Volume 30, Number 22. June 14, 2021  | Author: Nina Youngstrom  | June 14, 2021 

    A Colorado radiation therapy provider has agreed to pay $3.569 million in a civil monetary penalty settlement with the HHS Office of Inspector General (OIG)...

  10. Leveraging ADT, HL7 Data May Help Hospitals Prevent Denials

    Report on Medicare Compliance Volume 30, Number 22. June 14, 2021  | Author: Nina Youngstrom  | June 14, 2021 

    A Medicare auditor downcoded a hospital’s high-dollar MS-DRG claim for an implantable cardioverter defibrillator (ICD) because the cardiologist’s documentation didn’t square with Medicare’s revised national coverage determination (NCD 20.4).[1] There was no evidence of formal shared decision-making between the physician and the patient before the procedure using an evidence-based decision tool, and the medical necessity boxes weren’t checked, leaving the hospital to foot the bill for the device when the MS-DRG was changed to heart failure and shock...

  11. Checklist: Kicking the Tires of Your Telehealth Compliance

    Report on Medicare Compliance Volume 30, Number 22. June 14, 2021  | June 14, 2021 

    This checklist was developed by attorney Joseph F. Zielinski, with Dinsmore & Shohl. He spoke with attorney Katea Ravega of Quarles & Brady about implementing telehealth effectively and legally April 21 at the Health Care Compliance Association’s Compliance Institute.[1] Contact Zielinski at joseph.zielinski@dinsmore.com and Ravega at katea.ravega@quarles.com...

  12. CMS Transmittals and Federal Register Regulations, June 4-June 10, 2021

    Report on Medicare Compliance Volume 30, Number 22. June 14, 2021  | June 14, 2021 

  13. News Briefs: June 14, 2021

    Report on Medicare Compliance Volume 30, Number 22. June 14, 2021  | Author: Nina Youngstrom  | June 14, 2021 

    ◆ CMS’ supplemental medical review contractor (SMRC) is now doing postpayment reviews of Medicare claims for electrodiagnostic (EDX) testing axial muscles and spinal levels with 2019 dates of service, according to its website.[1]...

  14. CMS: MACs Will Start Audits for Post-March 2020 Claims, TPE Is Still on Ice

    Report on Medicare Compliance Volume 30, Number 21. June 07, 2021  | Author: Nina Youngstrom  | June 07, 2021 

    About 10 months after resuming medical reviews of claims submitted before COVID-19 smacked the world in the face, Medicare administrative contractors (MACs) are now free to include claims with dates of services during the pandemic, CMS said in an MLN Connects posted June 3.[1] That may shift the ground for hospitals and other providers, who have been submitting claims consistent with their understanding of the waivers of some conditions of participation (CoP) and regulations and may worry their interpretation will be challenged in audits...

  15. Tactics Get Uglier As Ransomware Attacks Rise; Forensic Reviews Help Get Hackers Out

    Report on Medicare Compliance Volume 30, Number 21. June 07, 2021  | Author: Nina Youngstrom  | June 07, 2021 

    The dollar amounts demanded in ransomware attacks and the viciousness of some tactics used to persuade organizations to part with the ransom are escalating, experts say, highlighting the magnitude of the cyber challenges they face. That raises the stakes for layered security, which has become more affordable, and for forensic investigations to help eject hackers from your computer systems if they manage to get a foothold...

  16. In FCA Case, DOJ Alleges Hospice Company Overruled Compliance Findings

    Report on Medicare Compliance Volume 30, Number 21. June 07, 2021  | June 07, 2021 

    When the compliance hotline at Curo Health Services Holdings, a hospice company, received a report in February 2012 about the admission of ineligible patients to its Avalon Hospice in Jackson, Tennessee, a compliance auditor and vice president of compliance audited 17 charts. They found at least six patients who allegedly were not appropriate for hospice and reported their findings up the chain. Not long after the investigation started, the director of operations at the Jackson hospice resigned, but that wasn’t a harbinger of change, according to allegations in a False Claims Act (FCA) complaint in intervention filed June 1 by...

  17. Medicare Forms: Second IMM May Be Trouble; HINN 11 'Is Underutilized'

    Report on Medicare Compliance Volume 30, Number 21. June 07, 2021  | Author: Nina Youngstrom  | June 07, 2021 

    When the attending physician is not on the same page as the rest of the medical team (case manager, physician advisor) about the medical necessity of continuing an inpatient admission, the hospital is required to give the patient the Hospital-Issued Notice of Noncoverage (HINN) 10, one of four HINNs in Medicare...

  18. The Four HINNs: A Quick Guide

    Report on Medicare Compliance Volume 30, Number 21. June 07, 2021  | Author: Nina Youngstrom  | June 07, 2021 

    Here’s a summary of the four different versions of the Hospital-Issued Notice of Noncoverage (HINN), which hospitals deliver to patients under certain circumstances.[1] There are other required Medicare forms, including the Important Message from Medicare and the Medicare Outpatient Observation Notice. This chart was developed by Tiffany Ferguson, CEO of Phoenix Medical Management. Contact her at tferguson@phoenixmed.net...

  19. CMS Transmittals and Federal Register Regulations, May 21-June 3, 2021

    Report on Medicare Compliance Volume 30, Number 21. June 07, 2021  | June 07, 2021 

  20. News Briefs: June 7, 2021

    Report on Medicare Compliance Volume 30, Number 21. June 07, 2021  | Author: Nina Youngstrom  | June 07, 2021 

    ◆ West Virginia-based Diabetes, Endocrinology & Lipidology Center Inc. (DELC) has agreed to pay $5,000 to settle a potential violation of the HIPAA Privacy Rule, the HHS Office for Civil Rights (OCR) said June 2.[1] This is the 19th settlement of an enforcement action in its HIPAA Right of Access Initiative. A complaint was filed with OCR in early 2019 alleging that DELC didn’t take timely action in response to a parent’s July 2019 request for her minor child’s protected health information. OCR investigated “and determined that DELC’s failure to provide timely access to the requested medical records was a...

  21. CMS: Billing Split Visits Is OK Despite Transmittal; Power of Good Guidance Rule Is on Display

    Report on Medicare Compliance Volume 30, Number 20. May 24, 2021  | Author: Nina Youngstrom  | May 24, 2021 

    CMS has given the green light to billing split/shared evaluation and management (E/M) services even though it removed all relevant guidance from the Medicare Claims Processing Manual. In Medicare Transmittal 10742,[1] which took effect May 9, sections on split/shared E/M services for providers in hospitals and nursing facilities have now been “left intentionally blank for future updates.”...

  22. Three Ascension Hospitals Pay $20M in CMP Settlement; One Allegation Is Free APPs

    Report on Medicare Compliance Volume 30, Number 20. May 24, 2021  | Author: Nina Youngstrom  | May 24, 2021 

    In a settlement that covers a variety of common hospital arrangements with physicians, Dell Seton Medical Center (DSMC) at The University of Texas, Ascension Seton Medical Center Austin (ASMCA), and Ascension Seton Williamson (ASW) agreed to pay $20 million to settle a civil monetary penalty (CMP) case. The settlement stems from Ascension’s self-disclosure to the HHS Office of Inspector General (OIG)...

  23. With More Demands on Compliance, It Needs to be ‘Agile,’ Experts Say

    Report on Medicare Compliance Volume 30, Number 20. May 24, 2021  | Author: Nina Youngstrom  | May 24, 2021 

    Compliance leaders increasingly ask three questions: How can they make compliance more cost effective, be more efficient and leverage data and technology to upgrade their risk monitoring? The answers to these questions may help organizations transform their compliance programs and make them more of a strategic business partner with operations, experts say...

  24. Modernizing Compliance Programs: How High Are Your Regulatory Risks?

    Report on Medicare Compliance Volume 30, Number 20. May 24, 2021  | Author: Nina Youngstrom  | May 24, 2021 

    Here’s a simple risk-assessment graph and some details about one of the productivity levers that can help compliance transform from reactive to proactive, according to Dhara Satija, senior manager at Deloitte & Touche LLP, and Thomas Delegram, a managing director at Deloitte & Touche LLP.[1] On the graph, the vertical column represents the degree of risk, and the horizontal column is for line-item transactions. “We start to figure out where to focus our time,” Delegram said. For example, “things with a high level of manual intervention that have high risks associated from a regulatory perspective will fall in the upper...

  25. CMS Transmittals and Federal Register Regulations, May 14-20, 2021

    Report on Medicare Compliance Volume 30, Number 20. May 24, 2021  | May 24, 2021